Healthcare Provider Details

I. General information

NPI: 1154875284
Provider Name (Legal Business Name): SPINE INSTITUTE OF FLORIDA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2016
Last Update Date: 05/02/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6536 GUNN HWY
TAMPA FL
33625-3853
US

IV. Provider business mailing address

7702 STILL PARK CIR
ODESSA FL
33556-2263
US

V. Phone/Fax

Practice location:
  • Phone: 813-803-0029
  • Fax:
Mailing address:
  • Phone: 727-637-8520
  • Fax: 813-949-8919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberOS14036
License Number StateFL

VIII. Authorized Official

Name: MARK NICHOLAS PERENICH
Title or Position: DO
Credential:
Phone: 813-803-0029